Please provide the following contact information:
First Name Last Name Title Organization Work Phone Home Phone E-mail
Select any of the certifications or specialty training which applies to you:
Open Water Certification Advanced Open Water Certification Dive Master / Instructor Science Diver Certification First Aid CPR
How many years diving?
How many dives in past 2 years?
Summarize any special skills or qualifications related to boating, diving, fund-raising, grant writing, photography, etc:
What special equipment or personal resources do you have such as boat, underwater camera, GPS, special software, etc?
Summarize your interest in the Taylor County Artificial Reef Program (even if it involves learning new skills or gaining accreditation) ?
Person to notify in an emergency:
First Name Last Name Relation Street Address Address (cont.) City State/Province Zip/Postal Code Cell Phone Home Phone
By checking this box, I affirm that the facts set forth in this form are true and complete to the best of my knowledge:
Agreement